No application will be rejected as a result of a disability that, with reasonable
accommodation, does not prevent performance of the essential job duties.

Information

First Name

Middle Int.

Last Name

Street Address

City/State

Zip Code

Phone

Work Phone

Date you can begin

Email

Position Applying For

Salary Desired

Education

High School

Name

City/State

Last Year Completed

Graduated

College or University

Name

City/State

Degree

Other

Name

City/State

Certificate/License

Special Skills

Software Applications

Other

Employment Record

Please list your most recent jobs first. Include military service as part of your employment record.

Employer Name

Address

Phone

Supervisor's Name

Job Title

Reason for Leaving

Start Date (month/year)

End Date (month/year)

Starting Salary

Ending Salary

Essential Job Duties

Employer Name

Address

Phone

Supervisor's Name

Job Title

Reason for Leaving

Start Date (month/year)

End Date (month/year)

Starting Salary

Ending Salary

Essential Job Duties

Employer Name

Address

Phone

Supervisor's Name

Job Title

Reason for Leaving

Start Date (month/year)

End Date (month/year)

Starting Salary

Ending Salary

Essential Job Duties

Additional Information

Please use the space provided to list any additional employers, periods of time not worked, or any other information
that you believe we should know in considering your application for employment.

General Information

May we contact your present employer?

Yes

Do you have the legal right to work in the United States?
(if hired, you will be required to provide identification to prove eligibility for employment)

Yes

Have you been employed or attended school using any other name?
If yes, please indicate names previously used:

Yes

Have you ever been convicted, pled guilty or no contest, or forfeited bond or bail for any crime other than traffic violations?
If yes, please explain:

(Conviction of a crime is not an automatic bar to employment. Factors such as the nature and gravity of the crime,
the length of time that has passed since the conviction and/or completion of any sentence, and the nature of the job
for which you have applied will be considered.)

Yes

Are you able to perform the primary duties of the job as outlined in the newspaper
advertisement, announcement, posting, job line, job description, with or without reasonable
accommodation?
If no, please explain:

Yes

Do you have any employment restrictions resulting from a non-compete or confidentiality agreement?
If yes, please explain:

Yes

PLEASE READ CAREFULLY, INITIAL EACH PARAGRAPH

I certify that I have answered the above questions truthfully and have not withheld any information
initial relative to my application. I understand that any falsification, misrepresentation, or omission, as well as
any misleading statements or omissions of the application information, attachments, and supporting
documents generally will result in denial of employment or immediate termination, if discovered after hire.

I authorize Anderson Bros., Inc. to thoroughly investigate my references, work record, education and
other matters related to my suitability for employment, and further authorize the references I have listed to
disclose to the company any and all letters, reports, and other information related to my work records,
without giving me prior notice of such disclosure. In addition, I release Anderson Bros.,
Inc., my former employers and all other persons, corporations, partnerships and associations from any and all claims,
demands or liabilities arising out of or in any way related to such investigation or disclosure.

I authorize Anderson Bros., Inc. to investigate whether I have a criminal record of convictions, and, if so,
the nature of such convictions and all the surrounding circumstances of the conviction. Anderson Bros., Inc.
has advised me that any criminal background check will focus on convictions, and that a criminal
record will not necessarily disqualify me from employment.

I understand that my employment and compensation can be terminated at any time, with or without cause, and with or
without notice, at the option of Anderson Bros., Inc, or myself. I understand that the President of the company is the
only person who has the authority to create any other terms of employment and/or to enter
into any employment contract and that all such contracts must be in writing and signed by both parties.
However, I also understand that unless otherwise stated in an employment contract, the company may change, withdraw and interpret
other policies (including wages, hours and working conditions) as it deems appropriate.

I understand and acknowledge that I may be required to submit to a physical examination, including a initial
drug test. Additionally, I hereby authorize the release of the results of such an examination to Anderson
Bros., Inc. for their use in evaluating my suitability for employment. Further, I release the examining
facility and Anderson Bros., Inc. from any and all liability, and from any damage that may result from the
release of such information.

Important Information To Know Before Submitting An Application for Employment With Anderson Bros., Inc.

All areas of the application must be filled out completely and accurately. Please fill in the required information directly on the application and do not indicate “see resume”.

If you are offered a position with Anderson Bros., Inc. be aware that we may verify all of the information that you have written on the application, as well as your resume. If there is a discrepancy in your information, the job offer may be withdrawn. It is important to be sure that what you have written is correct.

If you have any questions about completing the application, it is important to please ask the Anderson Bros., Inc. representative who has been assisting you.

Thank you for your cooperation.

Applicant Acknowledgement

My signature below indicates that I have read and understand the importance of supplying
accurate information on the application. I am also aware of the possibility of an offer of
employment being withdrawn if any of the information is not correct.